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� <br /> i <br /> � <br /> � Backwater Prevention Device Rebate Program <br /> Rebate Application Form ; <br /> -- -- — -- -- -- ------ — — j <br /> Propery O�vner Name:_ i,a�J�� L�h �����f- i <br /> Installation Address: � � (�� V,'�deJ j�L <br /> I i <br /> I ���'�-1'�'�`�� _ State:� Z, Ci�__2., 1 ' <br /> � <br /> � — �•— <br /> i Maifing hddress(iJdilf?rE+nt):____ <br /> Ci;y:--�_ Slalc: <br /> _ Z�p'--- <br /> � EmaiC,_ Phonc: ( )�_ <br /> ITotal Cosf to install Device (trom r,ontnclor invoiceJ: $_2 Su� . •" , <br /> � <br /> L_— ---- <br /> Please verify the follovifng: ' <br /> [�f am lhe cwner of the property�vhere !he bacicvrater prevention device eras in;taL'ed. <br /> Ly i v:orked���ilh the contraclor to determine the IocaUon (or the bac;cwater pravention device and <br /> understand tha, the decisior regarding the localion o(ihe device was mine. <br /> [-y,�'1'dy contractor ins�ucted me how In access, inspe;t, and maintain the device. <br /> �_�understand that I am responsible `or maintaining the 6ar.k�vater prevenlicn device and keeping <br /> it in good wnrking order, uNess it is instal'ad in tlie city right-of-w.ay. <br /> [u'�f I sell my property, I ti:�ill make potential buyers aware of the bacAivater prevention dev�ce and <br /> the need to inspect and maintain it on a ragular hasis. <br /> (y�i am enclosing all of Ihe necessary papora�ork(use the yellow Rebate Suhmittal Check'isi). <br /> Select from the following: <br /> ❑ 1 ho conlrar.tor identif�ed downspouLS or olher drainage Ilines lhat e�ero co�nected to my se�ve� <br /> linc(6etwer.n my hnuse nnd the insteiled device)and rernoved, or rerouted tltem. <br /> ��To my kno�vledye, my property has no dovanspouls or other drainage connected fo my sewer line <br /> (6e;�veen my hause and ihe ins,alled device). <br /> ❑ Thcre are da,vnspouls or olher drainage Iines conner.ted to my sewer line(behveen my house <br /> and the instal!ed device). I understand Ihat leaving thesu connections creales a nsk of fiooding <br /> and I accept;hal risk. <br /> Signature � Dafe ( �� `�� 1 <br /> �/ <br />